Consent to Treatment : Excel Adventist® Academy Missouri City TX

Student's Name

Student's Age

Date of Birth

Social Security Number

Home Address

Father's Name

Mother's Name

Guardian's Name

Please describe allergies:

Date of last tetanus shot

Family Physician 1 Name

Family Physician 1 Office Telephone

Family Physician 1 Address

Family Physician 2 Name

Family Physician 2 Office Telephone

Family Physician 2 Address

Hospital preference

Emergency Contact 1 Name

Emergency Contact 1 Phone

Emergency Contact 1 Address

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 2 Address

Parent's Electronic Signature

Date

A completed New Student Application.
Birth Certificate, Hospital Statement, Notarized statement, Passport or Visa (to verify birth date)
Immunization verification for all students as required by Texas Law. Students MUST have all vaccinations required for the appropriate age level.
Cumulative records and the student checkout sheet from the previous school attended.
Last report card (original)
Medical Exam
Vision/Hearing Screenings required by Texas state law for all first-time students ages 4 years (by September 1) through 8th grade. Screenings may be given by the student's primary doctor or Pinewood Screening Services on campus visit.

A completed Application Returning Form.
Updated Immunization Record
Vision/Hearing Screenings required by Texas state law for students who will be 4 years old by September 1 and those who are entering Kindergarten, 1st, 3rd, 5th, or 7th grades. Screenings may be given by the student's primary doctor or Pinewood Screening Services on campus visit.

Supporting documents can be faxed to 281-835-1275, or mailed to:

P.O. Box 2240
Missouri City, TX 77489

Excel Adventist^® Academy